What HIV self-testing may mean for couples

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A study in Malawi is offering glimpses into why couples opt
for HIV self-testing – including issues of trust and honesty – and what it may mean
for their relationships. Moses Kumwenda from the Malawi-Liverpool Wellcome
Trust Clinical Research Programme presented findings at the recent 2nd
International Conference for the Social Sciences and Humanities in HIV in
Paris.

Launched in 2012, the Hit TB Hard study in Malawi
investigates whether intensified tuberculosis (TB) case finding can curb new TB
cases. As part of this five-year cluster randomised trial, HIV self-testing is offered in half of the trial’s 28 clusters in order to facilitate targeted
HIV/TB prevention.

To evaluate the impact of self-testing on care-seeking and
couples’ relationships, researchers kept in touch with 66 people, including
seven serodiscordant couples, for a year after they had had an HIV self-test.

The researchers found that participants opted for self-testing
for a number of reasons, including risk behaviour, mistrust within the couple, and
a desire to either confirm an earlier HIV test result or check the effectiveness of local 'faith healing'. Some individuals used self-testing as an opportunity to
disclose a previously known HIV status:

“We were not using
condoms because I had not told my wife that I am positive. We were living
normally as a family because she did not know and I was so afraid to tell her.”

Couples struggled immediately after results to deal with
feelings of blame and disbelief, with men in particular being less willing
to accept results. This led some couples to re-test, as advised by both
researchers and the OraQuick self-testing kits, but also prompted others to
incorrectly assume that HIV discordance within longstanding relationships
indicated resistance to infection among partners who had remained HIV negative.

“I told him that we
should use condoms,” reported one woman who had tested negative for HIV
while her husband was HIV positive. “He
told me, ‘why is it that all this time you have not been infected? We should
live the way we have been living.’”

Men, who accounted for 44% of all those opting for self-testing
as part of the trial, generally had a harder time accepting the need to
practice safer sex than women. The study found that, while self-testing
increased the ability of HIV-negative partners within discordant couples to
negotiate condom use in the short term, men largely wanted to continue
practicing unsafe sex.

“We found that within discordant couples – regardless of
which partner was HIV-positive – males still preferred unprotected sex while
women were more concerned about preventing HIV transmission,” Kumwenda said. “Some
women reported trying to protect their marriages and the respect that they
enjoyed in the community by accepting whatever their husband was telling them
to do.”

One HIV-negative woman said:

“When you say no to
unprotected sex, he would ask you ‘where should I go to have sex?’ I married
you to be my wife.”

Social norms regarding definitions of a “good wife”,
including the need to sexually satisfy their partners and to bear children,
were cited as some of the reasons that women continued to be coerced into
unsafe sex – as were local beliefs that unprotected sex during pregnancy was important
to infant development.

While couples also reported experiencing fears regarding the
future of their relationships after self-testing, most couples were still
together a year after learning of their HIV statuses. Separation and physical
violence were only reported in one couple with a pre-existing history of domestic
violence.

Preliminary results suggest that, while HIV self-testing may
not introduce violence into relationships, it may exacerbate it in
relationships in which it already exists. This may indicate a need for
relationship counselling within HIV testing.

“There needs to be specialised counselling,” Kumwenda said.
“As testing is designed now, there is only pre- and post-test counselling but
there is nothing to assist couples who already have issues.”

Dr Nicola Desmond, also with the Malawi-Liverpool Wellcome
Trust programme, said that a larger study into the relationship between gender-based
violence and self-testing involving 300 participants is ongoing.

Making the move to self-testing

The study comes as the World Health Organization works to
develop guidelines on HIV self-testing following the first-ever WHO meeting on
the subject in April 2013.

South Africa, Kenya and Malawi are currently considering
adopting HIV self-testing to reach pockets that current testing campaigns
continue to miss, according to Nicola Desmond.

“In Malawi, I think there’s the realisation that HIV testing
uptake is ‘pocketed’ in the sense that there are certain groups being missed
either for initial or repeat testing,” she said. “In Malawi, we have HIV
testing campaigns once a year with door-to-door and mobile testing services but
there are a lot of people who are being missed.”

“We know that self-testing addresses (concerns) of
convenience and confidentiality and that these are some of the key things that
make testing attractive,” she added.

References

Kumwenda M et al. Complex Sexual Behaviour Among
Discordant Couples After Home HIV
Self-testing. 2nd International Conference for the Social Science and Humanities in HIV, Paris, session CS51, 2013. (View the abstract and download presentation slides on the conference website.)

Desmond N. The Social And Ethical Dimensions Of
Introducing HIV Self-testing
Technologies. 2nd International Conference for the Social Science and Humanities in HIV, Paris, session CS51, 2013. (View the abstract and download presentation slides on the conference website.)

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NAM’s information is intended to support, rather than replace, consultation with a healthcare professional. Talk to your doctor or another member of your healthcare team for advice tailored to your situation.